Temporomandibular Joint-Related Otalgia

Temporomandibular joint related otalgia is ear pain referred from the joint, masticatory muscles and surrounding structures when the ear itself is normal. The auriculotemporal branch of the mandibular nerve supplies both the joint and the external ear.

• It results from disc displacement, arthritis, bruxism, malocclusion, trauma or muscle spasm.
• It is commoner in young and middle aged women.
• Stress, jaw clenching, dental loss and gum chewing are common triggers.

Unilateral or bilateral pre auricular and ear pain, worse when chewing or yawning, jaw clicking or locking, limited mouth opening, facial or temple ache, and morning stiffness.

• Examination shows a normal tympanic membrane, tenderness over the joint or masseter and temporalis muscles, deviation on opening and reduced opening below 35 mm.
• Differential diagnosis: otitis externa, otitis media, mastoiditis, dental disease, parotitis, trigeminal neuralgia, giant cell arteritis, cervical spine pain, glossopharyngeal neuralgia, nasopharyngeal carcinoma.
• Complications: chronic pain, locked jaw, joint degeneration, tension headache, poor nutrition.

Clinical, after exclusion of ear and dental disease.

• Palpation of the joint and muscles, measurement of mouth opening, and assessment of occlusion.
• Otoscopy and dental examination; ESR and CRP if jaw claudication or age above 50.
• Panoramic radiograph, MRI of the joint for disc displacement, and nasopharyngeal endoscopy in persistent unilateral ear pain in adults.

Conservative management is effective in most patients.

• Supportive: soft diet for 2 weeks, avoid gum chewing and wide yawning, warm compresses for 15 minutes three times daily, jaw stretching and relaxation exercises, stress management, sleep position advice.
• Pharmacological: ibuprofen 400 mg three times daily with food for 1 to 2 weeks; paracetamol 1 g every 6 hours; amitriptyline 10 to 25 mg at night for chronic pain; diazepam 2 mg at night for up to 1 week for acute muscle spasm.
• Procedures: occlusal splint worn at night; physiotherapy; intra articular injection or arthrocentesis for locked joint; surgery for refractory structural disease.
• Special groups: pregnancy, heat, physiotherapy and paracetamol only; children, treat habits and dental alignment; older adults, avoid long term NSAIDs and check renal function.
• Red flags: jaw claudication with headache, fever with trismus, unilateral persistent ear pain with neck mass, trauma, progressive limitation of opening, numbness.
• Follow-up: review at 4 to 6 weeks; refer to oral and maxillofacial surgery if there is no response.